The Quadruple Aim in Healthcare. In God We Trust, Everyone Else Must Bring Data!
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1 The Quadruple Aim in Healthcare Achieving the Quadruple Aim in Healthcare with Empowered, Healthy and Evidence-based Nurse Practitioners Enhance the patient experience (includes quality) Improve population health Decrease costs Improve the work life of healthcare providers Bernadette Mazurek Melnyk, PhD, CRNP, FAANP, FNAP, FAAN Vice President for Health Promotion University Chief Wellness Officer Dean and Professor, College of Nursing Professor of Pediatrics and Psychiatry, College of Medicine Editor, Worldviews on Evidence-Based Nursing Executive Director, Helene Fuld Health Trust National Institute for EBP In God We Trust, Everyone Else Must Bring Data! The State of Healthcare and Health Preventable medical errors are a major cause of morbidity and mortality throughout the world (3 rd cause of death in U.S.) The delivery of evidence-based care is highly variable with estimates of it occurring only 50 to 55% of the time Poor quality healthcare costs billions of dollars every year Healthcare spending could be reduced by 30% if patients receive evidence-based healthcare 80% of chronic disease can be prevented with healthy lifestyle behaviors Depression will be the 2 nd most impairing disease worldwide by 2020 Current State of Health in Nurses State of Health in Nurses in 2012 U.S. Physicians Set Good Health Example Physicians in better health than nurses and employed adult population by Katie Bass and Kyley McGeeney October 3, 2012 see: Data based on 1,984 physicians and 7,166 nurses, conducted Jan. 2, 2011 to Aug. 31,
2 A National Study Links Nurses Physical and Mental Health to Medical Errors and Perceived Worksite Wellness (N=1790) Melnyk et al., 2018, Journal of Occupational and Environmental Medicine Health Status by Perceived Wellness Support & Stress at Workplace Percent of Nurses with Poor and Good Health with Medical Errors Errors and Shift Work From Melnyk et al, 2018, Journal of Occupational and Environmental Medicine xx 2
3 Considering All Causes of Morbidity and Mortality, Behaviors are the #1 Killer of Americans From a Small Coal Mining Town to Buckeye Nation: My Story Contributors to Premature Death Health Care Environmental Exposure 5% What Will the Last 10 Years of YOUR Life Look Like? Social Circumstances 15% Behavioral Patterns 40% Genetic Predisposition 30% Every day, we make behavioral choices that influence our health and wellness outcomes Based on Evidence, What Do We Know? People who have the following behaviors have 66% less diabetes, 45% less heart disease; 45% less back pain, 93% less depression, and 74% less stress Ford, Zhao, Tsai, Li, 2011 Physical activity - 30 minutes 5 days per week Healthy eating - 5 fruits and vegetables per day No smoking Alcohol in moderation - 1 drink per day for women, 2 drinks per day for men Add at least 7 hours per night of sleep and daily stress reduction for even better outcomes! 3
4 Kaylin s Story: Australian Dream Trip Turned Nightmare The Merging of Science and Art: EBP within a Context of Caring & EBP Culture and Environment Results in the Highest Quality of Patient Care Research Evidence & Evidence-based Theories EBP Culture & Environment Clinical Expertise and Evidence from assessment of the patient s history and condition as well as healthcare resources Clinical Decisionmaking Quality Patient Outcomes From Melnyk, B.M., & Fineout-Overholt, E. (2011). Implementing EBP: Real World Success Stories Patient Preferences and Values Melnyk & Fineout-Overholt, 2003 Acting on the Evidence Strength of the Evidence + Quality of the Evidence = Confidence to Act! Patient Outcomes With and Without Evidence-Based Practice Traditional Practice Evidence-Based Practice Why Must We Accelerate EBP? Despite an aggressive research movement, the majority of findings from research often are not integrated into practice to improve outcomes The gap between the translation of research into practice and policy is huge; It often takes decades to translate research findings into practice and policy The So What Outcomes Factor in an Era of Healthcare Reform Conducting research and EBP projects with high impact potential to positively change healthcare systems, reduce costs and improve outcomes for patients and their families Key questions when embarking on a research study or an EBP project: So what will be the end outcome of the study or EBP project once it is completed? So what difference will the study or EBP project make in improving healthcare quality, costs or patient outcomes? Measuring ROI is important! So what will I measure as outcomes that will help scale the findings when the project is complete? 4
5 COPE (Creating Opportunities for Parent Empowerment): An Evidence-Based Program to Improve Outcomes in Critically Ill/Hospitalized Young Children, LBW Premature Infants & Parents FUNDING FOR THIS WORK BY THE NATIONAL INSTITUTE OF NURSING RESEARCH R01#05077 NR S1 A 4 Day Shorter Length of Stay (LOS) for COPE Preterms Resulted in Cost Savings of $5000 per infant; 8 Day Shorter LOS for Preterms < 32 Weeks * NICU LOS * *p <.05 * 39.6 NICU + Transfer Hospital LOS COPE Comparison Why Must We Accelerate EBP? Tongue Patch for Weight Loss Step 0: Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: The Steps of EBP Cultivate a Spirit of Inquiry & EBP Culture Ask the PICO(T) Question Search for the Best Evidence Critically Appraise the Evidence Integrate the Evidence with Your Clinical Expertise and Patient Preferences to Make the Best Clinical Decision Evaluate the Outcome(s) of the EBP Practice Change Disseminate the Outcome(s) Clinical Inquiry Formulate a Searchable, Answerable Question (PICOT) Findings from our EBP Survey with U.S. Nurses (Melnyk et al., 2012, JONA Search for the Best Evidence Rapid Critical Appraisal, Evaluation, and Synthesis of Evidence Integrate the Evidence with Clinical Expertise and Patient Preference(s) Generate Evidence Internal: QI External: Research Over 1000 randomly sampled nurses from the American Nurses Association The more years in practice, the less nurses were interested in and felt it was important to gain more knowledge and skills in EBP Evaluate Outcomes based on Evidence Melnyk, Fineout-Overholt 2010 Disseminate the Outcome(s) 5
6 The One Thing That Prevents You From Implementing EBP 1. Time Organizational culture, including policies and procedures, politics, and a philosophy of that is the way we have always done it here. 3. Lack of EBP knowledge/education Lack of access to evidence/information Manager/leader resistance Workload/staffing, including patient ratios Nursing (staff) resistance Physician resistance Budget/payors Lack of resources 20 Total Responses 123 The National Chief Nurse Survey Melnyk et al., 2016, Worldviews on Evidence-based Nursing 93% currently in the CNO role Ages ranged from (M= 55 years) Years in practice ranged from 8-47 (M=31 years) Years as a CNO ranged from <1-32 (M= 9 years) 92% female; 94% White 6% bachelor s degree; 69% master s degree; 8% PhD prepared; DNP prepared 45 States and DC represented 18% work in Magnet facilities 55% reported having clinical ladder systems 47% had no ongoing nursing research projects 90% 80% EBP Priorities CNOs EBP Beliefs I am sure about how to measure the outcomes of services provided to patients 35% 70% 60% How important is it for you to build & sustain a culture of EBP? 30% 25% 50% 20% 40% 30% 15% 20% How important is it for your organization to build & sustain a culture of EBP? 5% 0% 0 = Not at all Important = Extremely Important 0% 1 = Strongly Disagree 2 3 = Neither Agree/Disagree 4 5 = Strongly Agree Organizational Readiness In your organization, to what extent is there a critical mass of nurses who have strong EBP knowledge & skills? 25% Top Priorities As a CNO/CNE, what are the top priorities that you are currently focused on in your role? 35% 20% 30% 25% 15% 20% 15% 5% 0% 5% 0% 1 = Not at all 2 3 = Somewhat 4 5 = Very Much 6
7 60% Performance Metrics Core Measures EBP Competencies for Practicing Nurses and Advanced Practice Nurses 50% 40% 30% 20% 0% Catheter Pressure Ulcers Associated Urinary (Stage 3 and 4) Tract Infections Vascular Catheter Falls and Trauma Associated Infections Manifestations of Poor Glycemic Control Below National Rate Same as National Rate Above National Rate The Establishment of Evidence-based Practice Competencies for Practicing Registered Nurses and Advanced Practice Nurses in Real-World Clinical Settings: Proficiencies to Improve Healthcare Quality, Reliability, Patient Outcomes, and Costs 2014 Download free at: Bernadette Mazurek Melnyk, RN, PhD, CRNP, FAANP, FNAP, FANN Lynn Gallagher-Ford, RN, PhD, DPFNAP, NE-BC Lisa English Long, RN, MSN, CNS Ellen Fineout-Overholt, RN, PhD, FAAN The First U.S. Study on Nurses EBP Competencies Indicates Major Deficits that Threaten Healthcare Quality, Safety and Patient Outcomes Aims: describe the state of EBP competency in nurses across the U.S. determine important factors associated with EBP competency Methods: Cross sectional anonymous descriptive survey with nurses across the U.S. Sample: 2,344 nurses from 19 hospitals/healthcare systems Mean age = 44.5 years 92% female 85% non-hispanic White 58% had a bachelor s degree 69.2% worked in a Magnet organization Correlations among EBP Competency and EBP Culture, Knowledge, Beliefs and EBP Mentoring Mean (SD) Pearson Correlation Coefficient Competency Culture Knowledge Beliefs Culture 80.2 (21.9) 0.29 Knowledge 19.5 (7.0) Beliefs 56.7 (8.5) Mentoring 21.4 (10.9) P < for all the Pearson correlation coefficients State of Self-reported EBP Competencies by Nurses Across the United States (N = 2075) Making Use of the Competencies The new EBP competencies should be integrated into healthcare system orientation programs, clinical ladders, and performance appraisals Incorporating the competencies into real world practice and academic settings will assist healthcare systems in improving quality, safety, and patient outcomes as well as reducing costs! 7
8 Creating a Culture and Environment to Sustain EBP and Healthy Work Environments What Works Remember, Culture Eats Strategy! The only person that likes a change is a baby with a wet diaper! Critical Components of an EBP Culture Critical Components of an EBP Culture A Philosophy, Mission and Commitment to EBP: there must be commitment to advance EBP across the organization as evidenced in orientation, clinical ladders, evaluations Administrative Role Modeling and Support: leaders who value and model EBP as well as provide the needed resources to sustain it A Spirit of Inquiry: health professionals are encouraged to continuously ask questions, review and analyze practices to improve patient outcomes Infrastructure: tools and resources that enhance EBP across the organization; computers for searching upto-date data bases, library resources EBP Mentors: who have in depth knowledge and skills in EBP, mentoring others, and overcoming barriers to individual and organizational change Recognition: individuals and units are rewarded regularly for EBP Assessment of Organizational Culture & Readiness for EBP* *Scale Developed The ARCC (Advancing Research and Clinical practice through close Collaboration) Model + Based on the EBP paradigm & using the EBP process Potential Strengths Philosophy of EBP (paradigm is system-wide) Presence of EBP Mentors & Champions Administrator/Leader Support Identification of Strengths & Major Barriers to EBP Implementation Potential Barriers Lack of EBP Mentors & Champions Inadequate EBP Knowledge & Skills Low Beliefs about the Value of EBP & the Ability to Implement it EBP knowledge* Beliefs about the Value of EBP & Ability to Implement the EBP Process* Use of EBP Mentors; Perceived EBP Mentorship* Implementation of ARCC Strategies, including Interactive EBP Education and Skills Building Workshops EBP Rounds & Journal Clubs EBP Implementation*+ Job Satisfaction Group Cohesion Intent to Leave Turnover Decreased Healthcare System Costs Higher Quality Healthcare and Improved Patient Outcomes Melnyk & Fineout-Overholt 2005; Revised, 2017 ARCC = Advancing Research & Clinical practice through close Collaboration Outcomes of Implementing the ARCC Model at Washington Hospital Healthcare System Early ambulation in the ICU resulted in a reduction in ventilator days from 11.6 to 8.9 days and no VAP Pressure ulcer rates were reduced from 6.07% to.62% on a medical-surgical unit Education of CHF patients led to a 14.7% reduction in hospital readmissions 75% of parents perceived the overall quality of care as excellent after implementation of family centered care compared to 22.2% pre-implementation Melnyk et al., 2017, Worldviews on Evidence-based Nursing 8
9 The simple provision of resources and dissemination of information alone will not lead to uptake of EBP A key ingredient for success is persistence as there will be many character-building experiences along the way!! A multi-component active strategy is necessary, including behavior and organizational culture change strategies At least I have found 9000 ways that it won t work." Thomas Edison Worldviews on Evidence-Based Nursing Linking Evidence to Action Editor Bernadette Melnyk, PhD, CNPN/PMHNP, FAANP, FAAN Gives readers methods to apply best evidence to practice Global coverage of practice, policy, education and management From a source you can trust, the Honor Society of Nursing, Sigma Theta Tau International Ask yourself: What will you do if you know you can not fail in the next 2 to 5 years? What is the smallest EBP change that you can make tomorrow that would have the largest positive impact for your patients outcomes? because we ve always done it that way.?? Nothing Happens Unless First a Dream! Carl Sandburg 9
10 The Helene Fuld Health Trust National Institute for EBP in Nursing & Healthcare took 10+ years for the dream to become reality Inaugural Fuld National Summit held October 19-20, 2017 See Participating Organizations/Agencies in the First Fuld Invitational EBP Expert Forum on October 18, 2017 AMSN AcademyHealth AHRQ AAN AACN AACP AACN AANP ACCP ANA ANCC AONE APNA APHA ACTS ANPD AORN AWHONN CDC CMS Duke HPIO ICN McMaster MSKCC NAP NAM NAP (Nursing) NAPNAP NASN NIH/NINR NLN NONPF NCH ONS QSEN STTI Daisy Foundation OSU OSUWMC USAF VA ONS The Next 2-5 Years What will you do in the next 2 to 5 years if you know that you cannot fail? Dream, Discover and Deliver Just Do It! Final Motivational Words Shoot for the moon, even if you miss, you will land amongst the stars -Les Brown There Is A Magic In Thinking Big! Contact Information Copyright, 2018 Bernadette Mazurek Melnyk melnyk.15@osu.edu Follow me on 10
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